022 Assistive Technology 2013

33
Snapshot Review
Review of current and emerging
assistive technologies for the
reduction of care attendant hours:
cost effectiveness, decision making
tools and emerging practices
Authors: Rachael McDonald, Nikos Thomacos,
Katherine Inglis
3 April, 2013
Research report#: 0413-022-026-RR1
Accompanying documents to this report

Title:
Report number:
Apps Master List
Overview of Methods of studies
This evidence reviewre

report was prepared by
Dr Rachael McDonald, Department of Occupational Therapy and CDDHV, Monash
University
Dr Nikos Thomacos, Department of Occupational Therapy, Monash University
Ms Kathy Inglis, Department of Occupational Therapy and CDDHV, Monash
University
for
Dr Suzanne Snead and Ms Gillian Robertson
TAC
Acknowledgements
Mr David Lester, Samantha Barker, and Bianca Chan.
Please Note: This Evidence Review has been produced by the Evidence Review Hub of the Institute for Safety,
Compensation and Recovery Research (ISCRR) in response to a specific question from TAC.
The content of this report may not involve an exhaustive analysis of all existing evidence in the relevant field, nor
rd
does it provide definitive answers to the issues it addresses. Reviews are current at the time of publication, 3
April, 2013. Significant new research evidence may become available at any time.
ISCRR is a joint initiative of WorkSafe Victoria, the Transport Accident Commission and Monash University. The
opinions, findings and conclusions expressed in this publication are those of the authors and not necessarily
those of TAC or ISCRR.
ISCRR Research Report# 0413-022-026-RR1
Page 3 of 33
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Contents
Item
Page
Executive Summary
Background
The Research Question(s)
Method
Results
11
Implications and Conclusions
23
References
26
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Executive Summary
Assistive Technologies (AT) is a rapid growth area to enhance participation, freedom
from personal supports and enablement of self-determination for people with brain
and spinal cord injuries. With the advent of new and emerging technologies both
mainstream and specialised there is limited evidence of the effectiveness of the
technologies. Other areas that are lacking include appropriate assessment and
evaluation of the technology, the person performance with the technology as well as
the economic implications of providing and supporting these technologies.
This project was driven by the above concerns by members of the TAC. There are
increasing numbers of claims or requests for new and emerging technologies, and a
decision making tool around assessing the credibility of claims is being developed by
the sponsor. The purpose of this review was to scan the available literature, and
provide a snapshot overview of the evidence available to help with this.
This was a 12 week iterative process, where the project sponsors and research staff
spoke on a weekly basis to review the information and suggest future directions.
What that means is that there is a large number of references gained and sourced
but the quality of these articles has been measured in the most rudimentary way.
Further, in depth review is required to add to the discussion here.
The literature was searched using a number of keywords. Databases, conference
proceedings and grey literature were sourced, resulting in 457 articles, which were
reduced to 203 in final analysis. The final analysis showed that the vast majority of
papers were opinion pieces.
There were three research questions which have been addressed in the main body
of the report. However, a fourth area economic benefit or otherwise arose from the
weekly meetings and the research literature. Thus we have included an economic
analysis to help to put perspective on the results.
In summary, this report highlights the paucity of plausible literature in this field, and
recommendations around this have been made. Of central importance is the
workforce understanding their role in emergent technologies, longitudinal economic
analysis of the effectiveness or otherwise of AT, and the need for robust but flexible
outcome measurement in this field.
Page 5 of 33
Background:
re
Assistive technologies (AT) are a rapidly developing area of practice for people with
brain and spinal cord injuries, and the use of AT to ameliorate and enable people
with disabilities to achieve participation in communication, community activities, selfcare, productivity and leisure is constantly being updated. The most widely accepted
definition of AT is that provided by the United States of Americas Public Law (PL)
108-364 of the Assistive Technology Act (1998, amended 2004), which states that
an assistive technology device is:
Any item, piece of equipment or product system, whether acquired
commercially off the shelf, modified or customized that is used to increase,
maintains or improve functional capabilities of individuals with disabilities (as
quoted in Cook & Polgar, 2008, p.5).
There are several important concepts in this definition. Firstly, an AT device can be
any device, where the purpose is to assist an individual to participate in activities.
This includes technology that is mainstream or used by all the population,
mainstream technology that is modified and technology that is designed specifically
for people with cognitive and/or physical impairments.
The context of this review is that there are increasing numbers of requests for
assistive technology products from TAC clients. These technologies may be readily
available in the consumer market, but increasingly new and emerging technologies
are requested that have (a) a limited research evidence base for improved outcomes
and (b) can result in additional and increasing costs, both for the equipment itself
and the support required to use the technology, or (c) significantly reduce costs.
Models for provision of technology

Models of provision of AT are different between schemes, states and countries.
Attempts have been made to standardise assistive technology services based on a
common language and evidence base (Elsaesser & Bauer, 2011), but this remains
problematic for two reasons. Firstly, the quality of evidence remains low, with much
of the peer reviewed literature based on opinion. Secondly, the provision of
emerging assistive technology remains inconsistent.
Difficulties receiving, maintaining and financing assistive technologies remain a
common problem (Henschke, 2012; Hubbard Winkler et al., 2010). Additionally AT
is so rapidly developing, that the workforce is often unprepared (Lewis, Cooper,
Seelman, Cooper, & Schein, 2012).
Page 6 of 33
re to Increase Independence
Assistive Technology
Previous definitions of independence are based around the notion of reduction in the
need for personal care and increase in safety (Barbara and Curtain, 2008).
In 2011, the TAC introduced the independence model for their clients with severe
injuries (TAC, 2011). The liability for people with long term injuries was continuing to
increase, together with increasing attendant care costs, non-measurement of client
outcomes and plateauing of client satisfaction (TAC, 2011). The aims of the
independence model are to ensure reasonable costs in long term, whilst enabling
meaningful client outcomes.
The dictionary definition of independence states that independence is freedom from
the control, influence, support, aid or the like of others (Dictionary.com, 2013). In
terms of independence of people with disabilities, it is worth referencing two further
sources the UN convention on rights of persons with a disability (2008) and the
productivity commission report on disability care and support (2011).
The productivity commission report on Disability Care and Support (2011) states that
services aim to maximise peoples independence and participation in the community.
The commission uses the social model of disability health, and uses the concept of
participation often interchangeably with independence. They describe the use of
opportunities for people with disabilities to achieve potential for social independence.
Social independence relies on the enablement of choice and innovation in all life
areas including self-help, social skills, literacy and numeracy. To achieve this, they
recommend facility and home-based activities, activities offered to the whole
community as well as supervision and physical care.
To further the discussion of the meaning of independence, the UN Convention on the
rights of persons with disabilities adopts a social model of disability. Their version of
independence is full and effective participation in society on an equal basis with
others (UN General Assembly., 2007). These concepts are more inclusive than
previous definitions of independence, which focussed on personal assistance.
However, in terms of measuring outcome, provide further difficulties.
Research Questions
This snapshot review has been conducted for the TAC to answer the following
questions:
1. What is the effectiveness of low, medium and high assistive technologies in
reducing attendant care hours? Evidence from aged care may be available
and relevant for providing a basis.
2. What are the trends in the disability sector for emerging technologies such as
i-Pad, i-Pod, smart, and tablet devices, in particular for people with ABI?
3. What are the emerging technologies reported?
Page 7 of 33
Although the researchrequestions were developed through negotiation at the

commencement of the project, the process of this review was unusual, in that the
process was an iterative discussion of articles and findings as they emerged. The
reason for this was to ensure that the material sourced was that which met the
sponsors needs. This has resulted in a high number of articles, of varying quality.
Quality assessment was performed only through examination of the methodology
Method
This is a snapshot review based on research questions developed using an iterative
process between the researchers, TAC staff, and ISCRR. This review was not
intended to provide an exhaustive search of the available literature; rather its
intention was to provide an overview of the current and emerging trends in assistive
technology (AT). Literature published between 2007 and 2013 was scanned and
searched with regards to ABI, and SCI initially, but expanded to include literature
from ageing research, dementia research and other developmental disability if the
technology was relevant.
The search process was an iterative process, guided by weekly meetings between
the sponsoring and research teams. Thus, research questions were expanded
during the process to include different populations (aging, dementia and
developmental disability) as well as excluding other articles (those relating to smart
homes and robotics, except when specifically related to attendant care).
Quality was briefly assessed using only the methods used as described in the
articles. This is not entirely robust. For example, McDonald et al (2011), used a
randomised control trial methodology to compare the efficacy of electronic diaries
with paper diaries for people with an acquired brain injury. Whilst the methodology
was sound the trial consisted of only 12 participants, meaning that the
generalizability of its results is low. However, this level of detail is beyond the scope
of this review. Thus, systematic methodology of literature review was not possible
and remains a limitation of the review.
Articles were selected for full scan/review based on their topic (i.e. being related to
emerging technology, attendant care, reduction or measurement of attendant care
hours, economic rationale). These were further excluded if not related to the final
agreed terms.
The search strategy is described in further detail below.
Page 8 of 33
re STRATEGY
SEARCH TERMS AND
1. Database search: Table one shows the search terms used.
Search Terms:
Assistive
technology/devices
Smart technology
Electronic device
iPad/Tablet computer
iPhone/Mobile/Cell
phone/Android/
Touchscreen
Smartphone
Communication device
Independence
Cognitive/memory aid
Quality of life
Emerging/new technology
Assistive technology
trends
Apps/applications
Function/Functional
independence
Access/Alternative
access
ABI/TBI/brain injury
Attendant care/
Cost effectiveness
Supported care
Economics
Severe injury
Home/community-based
care
Disability technology
SCI
ADL
Low/Med/High Assistive
Technology devices
Aged care
AAC device/technology
Mobility
Aids and equipment
Disability
Electronic diaries
Intuitive technology
Universal design
Table 1: Search Terms
Searches:
Using the above keywords, both in singular and combination forms, databases were
searched with the limits of year (2007 onwards) and English Language. Abstracts
were scanned, and where the article met the criteria full texts were sought.
The databases searched included: CINAHL plus (159 articles), Medline (52 articles),
Cochrane Database of Systematic Reviews (6 articles), Informit (12 articles), Taylor
Page 9 of 33
re PsychINFO (69 articles), Science Direct (91 articles), Sage

and Francis (54 articles),
(43 articles).
Hand Searching was completed for the following Journals: Disability and
Rehabilitation: Assistive Technology (65 articles), Technology and Disability (45
articles), Augmentative and Alternative Communication (18 articles), Assistive
Technology (37 articles), and Journal of Assistive Technologies (31 articles).
Conference proceedings included Rehabilitation Engineering and Assistive
Technology Society of North America (RESNA) (22 articles), Australian
Rehabilitation Assistive Technology Association (ARATA) (11 articles),
Communication Matters (Comm Matters) (4 articles), Recent Advances in Assistive
Technology and Engineering (RAate) (5 articles), Australian Group of Severe
Communication Impairment (AGOSCI) (2 articles) and American Speech-Language
Association (ASHA) (6 articles).
The references, together with copies of the articles, were uploaded into Endnote V6
database, and duplicates removed, resulting in 480 articles with abstracts reviewed.
From these, a further 23 were removed resulting in 457 articles briefly reviewed in
full.
The economic literature was sourced from 2000 onwards. This economic analysis
was performed in addition to the research questions. Articles around the provision of
economic rationale were sourced, read, reviewed, and synthesised.
Page 10 of 33
Results
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General Information:
This section has been divided into five separate sections: Sections 1, 2 and 3 will
attempt to answer the research questions, divided into separate sections where
relevant. Section 4 attempts to address the economic rationale for provision of AT.
Section 5 outlines the potential barriers to use of AT.
Assistive technology potentially enhances wellbeing, enhances independence and
enables people to live at home. Commonly available technologies enable people
with ABI and SCI to compensate for difficulties performing daily living tasks(Larsson
Lund, Lvgren-Egstrm, & Lexell, 2011; Larsson Lund, Lvgren Engstrm, & Lexell,
2012; Rigby, Ryan, & Campbell, 2011). The evidence however for new and
emerging technologies remains scant.
Quality of Literature
The quality of the information sourced was generally poor, with the following
breakdown: opinion (60 articles), review (19 articles), case study (47 articles),
uncontrolled trial (59 articles), and controlled trial and systematic review (18 articles).
These results are consistent with the reported literature, that highlights that the
majority of the research evidence is at the level of personal opinion, case study or
uncontrolled study level, with small sample sizes (Antilla, Samuelsson, Salminen, &
Brandt, 2012; Tai, Blain, & Chau, 2008). In terms of value for money, the potential
impact with relatively low cost implications potentially make AT a cost effective
intervention (Bamer, Connell, Dudgeon, & Johnson, 2010). However, it is difficult to
separate optimism and enthusiasm for new technologies from evidence around the
effectiveness of available AT. Evidence on the efficacy of AT needs to be
investigated, and professionals who work in this field require knowledge and hands
on experience (de Joode, van Boxtel, Verhey, & van Heugten, 2012).
The effectiveness of AT to reduce personal care is important, as people using more
complex technology devices are more likely to also use formal care services (Agree,
Freedman, Cornman, Wolf, & Marcotte, 2005). Cognitive deficits and low selfefficacy reduce the ability of people to use complex technologies (Alvseike &
Bronnick, 2012). People with ABI require more mental effort, and take longer to
complete tasks than the general population, but are often able to effectively use
electronic devices to enable participation, either with or without supports (Boman,
Rosenberg, Lundberg, & Nygard, 2012; Boman, Tham, Granqvist, Bartfai, &
Hemmongsson, 2007; de Joode, van Boxtel, et al., 2012; Fish, Manly, Emslie,
Evans, & Wilson, 2008).
The speed at which apps for mobile operating systems have become available is
overtaking the speed at which users, clinicians and prescribers can keep up.
Principles of matching the app and device to the needs of the consumer can often
get lost (Gosnell, 2011; Gosnell, Costello, & Shane, 2011). Furthermore, much of
Page 11 of 33
re developing; for example, the use of iCloud for storage of

the technology is rapidly
information; use of iPad, iPhone and other devices as electronic controllers of AT
(replacing traditional infra-red technologies); and, the use of these smart
technologies as safety and security devices. There were no articles identified on the
use of these newer technologies.
1. What is the effectiveness of low, medium and high assistive
technologies in reducing attendant care hours? Evidence from aged
care may be available and relevant for providing a basis.
Personal Care and Independent Living
The capacity of equipment to substitute for, or supplement personal care has been a
convincing argument, for some years (Agree & Freedman, 2011; Agree et al., 2005).
Technology has been shown to have potential to improve quality of life (Agree &
Freedman, 2011; Agree et al., 2005; Blaschke, Freddolino, & Mullen, 2009; Boman
et al., 2007; Brandt & Alwin, 2012; Rigby et al., 2011), but the qualifications for this
(especially in terms of participation) are not as clear. Consistently, assistive
technologies such as environmental control units (ECUs) have been shown to
decrease the need for personal assistance in certain populations such as people
living with spinal cord injury. This tends to be a reduction in care hours, rather than
replacement (Hoenig, Taylor, & Sloan, 2003), although the reduction in care hours
has been as dramatic as 2.5 times less than people who didnt use these devices
(Rigby et al., 2011).
ECUs are reported to improve functional abilities and participation whilst reducing
support needs (Brandt, Samuelsson, Tytri, & Saliminen, 2011). Traditionally,
these devices have worked on infra-red controllers, leading to a high level of
abandonment. Infra-red devices are rapidly being replaced by wireless technologies
used in mainstream society (e.g. in TV and music systems), which also, have the
potential to be used to control the environment. The utility of iPads for easy access
environmental control devices has been suggested (Alvseike & Bronnick, 2012). A
simple ECU is built into the iPad as standard, with low cost accessories easy to
purchase, use and install. What needs to be explored further is the potential for
universal environmental control by iOS (iPhone/Pad operating system) or android
technologies. Presently, there is little reference to this in the literature.
For people with cognitive impairment, software for enabling decision making around
activities of daily livings, memory prompts, and structured decision making have
been developed, but not robustly measured (Oldreive, Moore, & Waight, 2012).
Personal Care and Independent living from Aging literature
People aging with a disability have been found to have a slower decline in function
when using AT and/or home modifications. Additionally, this group were also likely
to use equipment to maintain independence in personal care activities (Wilson,
Mitchell, Kemp, Adkins, & Mann, 2009). Sensors that detect moisture which are
Page 12 of 33
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connected to mobile technologies
(hence, enabling freedom of community access or
prevention of pressure ulcers) have been discussed, but not formally evaluated
(Fernandes, Gaydecki, Jowitt, & van den Heuvel, 2011; Nijhof, van Gemert-Pijnen,
de Jong, Ankon, & Seydel, 2012).
CareTV shows promise at providing support through mainstream technologies (van
den Heuvel, Jowitt, & McIntyre, 2012). CareTV is a concept where a person can set
up reminders, interact with health professionals, and use a personal alarm through
wireless or smart televisions. Traditional personal emergency response systems
have been available for a long time, but their utility and availability has been scarce.
Improvements in home monitoring systems show promise (Hessels, Le Prell, &
Mann, 2011), but have been found to need specific practitioner expertise and
alternative people (or hybrid) supports for environmental emergencies (King &
Williams, 2008).
One issue, for people living with dementia, is the risk of wandering. This is also a
risk for some people with ABI and cognitive impairments. Recent developments
include using lower end, readily available technologies in new ways such as using
sleep monitors (actigraphs) to detect wandering; again these are ideas rather than
proven interventions. Telecare monitoring has been shown to offer people an
alternative means of support when they are unable to perform tasks for themselves
(Cameron & Doughty, 2010). Telecare is inherently appealing for supporting people
within their own homes, but often considerable support is needed to use them
(Doughty, 2008; Doughty, Godfrey, & Mulvihill, 2012). Electronic surveillance and
tracking techniques to monitor people at risk of wandering are continuously being
developed, but practical and ethical issues remain (Hughes, 2008)
Memory Supports, Reminder aids and Electronic Diaries
Low cost strategies for memory aids such as a pager show promise to compensate
for memory loss, but are not always sustained once input had ceased (Fish et al.,
2008). Personal Digital Assistants (PDAs) have also been shown to have promise
as a memory tool (Gentry, 2008), however, this technology is disappearing from the
shelves and is being replaced by smart phone technologies. Other low cost
technologies, such as a digital calendar with message board, have been found to
support older people (Holthe & Walderhaug, 2010), but again, their use is not
necessarily continued without support.
When looking at new and emerging technologies, television-assisted prompting
(TAP) systems, (such as CareTV), encourages adherence to regimes, without a
person having to leave their home (Lemoncello, Moore Sohlberg, Fickas, Albin, &
Harn, 2011). When used with people with ABI, TAP has been shown to improve
memory prompting, higher task completion and participation (Lemoncello, Sohlberg,
Fickas, & Prideaux, 2011). Other home based electronic memory aids have been
shown to assist the user to carry out activities in their own environments, however,
additional supports are required for setting up and monitoring these (Boman, Bartfai,
Borell, Tham, & Hemmingsson, 2010).
Page 13 of 33
re people with ABI, have shown that reminder prompts and

Studies specifically with
messages through Telecare, other electronic devices or computerised promptings
(e.g. calendar software) are supportive of independence in personal care post
inpatient rehabilitation (Boman et al., 2010; Boman et al., 2007; Costa & Doughty,
2009). However, people with ABI, do require training and multidisciplinary support to
use these effectively (de Joode, Proot, van Heugten, Verhey, & van Boxtel, 2012;
McDonald et al., 2011).
In a literature review of people with MS, electronic memory aids were not found to
have sufficient evidence to support the effectiveness of memory rehabilitation;
however, this was due to the limited quality of studies in the area (das Nair,
Ferguson, Stark, & Lincoln, 2012). This remains the case with evidence for people
with injury of a traumatic nature.
Access to and control technologies
New technologies are only useful for people with disabilities when they are able to
access and control them. For example, touchscreen devices offer people direct
access to a device, but the screens may be overly sensitive when used by people
with motor impairments, such as spasticity. As technology develops, refinements to
mainstream access continue to evolve.
Mainstream technologies are improving in their intuitive access (Chung, Beebe,
Berends, & Hardcastle, 2012), thus, improving accessibility. Development of
intelligent software alongside touchscreen technologies that can configure input
devices for people with physical impairment by bypassing keyboards are reported
(Horstmann Koester, Lopresti, & Simpson, 2007). Development of dampening
techniques to improve input to desktop computers have been developed (such as
tracker balls), and other dampening techniques are in development (Wobbrock &
Myers, 2008). Experimental devices that show promise include making tiny
intentional contraction of a single muscle to make an onscreen choice (Alves &
Chau, 2011; Felzer, Beckerle, Rinderknecht, & Nordmann, 2010). An extension of
this is the potential of brain computer interfaces (BCIs), via an interface such as an
EEG, for people who have high level paralysis (Pasqualotto, Federici, & Belardinelli,
2012). One device the EPOC neuroheadset enables people to use their facial
expression to control a computer. Its wider use by people with disabilities remains to
be established (Lievesley, Wozencroft, & Ewins, 2011).
For people who are currently unable to access mainstream technologies, there is a
body of reported case study work for individual solutions, such as sip and puff
switches (Jones, Grogg, Anschultz, & Fierman, 2008), or speech/vocal driven
systems (Judge, Robertson, Hawley, & Enderby, 2009; Judge, Robertson, & Hawley,
2011), or tongue input (Kencana & Heng, 2009; Lontis & Struijk, 2010; Mace,
Page 14 of 33
Vaidyanathan, Wang,re
& Gupta, 2009). These access input devices tend to be one
off devices, and their use with emerging technologies is not reported.
Other alternative access methods that show promise include eye gaze technologies
(i.e. access via eye pointing on a computer screen) (Ball et al., 2010; Biswas &
Langdon, 2011; Fager, Bardach, Russell, & Higginbotham, 2012; Najafi, Friday, &
Robertson, 2008). For those who have eye conditions that compromise eye
movement (e.g., nystagmus) eye-gaze technology may not be a viable option and
head pointer devices may provide an alternative. A head pointer may be easier to
use because it involves touching the pointer to the screen, but may not be as
functional in terms of access to mainstream technologies as eye gaze (Fager,
Bardach, et al., 2012; Fager, Jakobs, Beukelman, Ternus, & Schley, 2012; Kjeldsen,
2008).
Speech recognition technology traditionally excludes people with dysarthric speech,
however, over time, they have become more useable by people with less clear
speech (Young & Mihailidis, 2010). Voice activation of joysticks to enable access to
computing and powered mobility are now at the stage of being comparable to regular
joystick use (Harada, Landay, Malkin, Li, & Bilmes, 2008)
Mechanisms to enhance access such as visual display for speech generating
devices to improve the human-machine interface are reported (Wood Jackson,
Wahlquist, & Marquis, 2011). Data gloves, where sensors detect the movement of
hands and connect with a computer have been developed, but the high cost of
sensor technologies make these prohibitive technologies at present (Tongrod,
Lokavee, Watthanawisuth, Tuantranont, & Kerdcharoen, 2013).
When people are able to use their hands to operate technology, producing words via
swipe or word prediction are useful ways of inputting text into an electronic device for
people with ABI (Anson, Brandon, et al., 2012). Several methods can be used to
make text more accessible such as replacing or augmenting a computer mouse or
mouse cursor(Anson, Smith, & Hirschman, 2012; C. T. Shih, Shih, & Luo, 2011),
integrating additional pointing devices, or utilising alternative computer inputs (C. H.
Shih & Shih, 2010a, 2010b).
Enhancement of mobility
Mobility remains an area of high importance for people unable to walk independently,
and the use of mobility aids often increases the need for attendant care.
Increasingly, methods for enabling people with complex disabilities to independently
acquire mobility are a focus of development. Development of intelligent wheelchairs
(Zeng, Teo, Rebsamen, & Burdet, 2008), and those with anti-collision technology
(Wang, Gorski, Holliday, & Fernie, 2011; Wang, Kontos, Holliday, & Fernie, 2011)
are areas to watch for in the future. Hum-controlled wheelchair systems for people
with motor and speech impairment (Falk, Andrews, Hotz, Wan, & Chau, 2012), as
well as wheelchairs controlled and navigated using a single switch (Ka, Simpson, &
Page 15 of 33
Chung, 2012) are all re

presently in development. Using single switches to navigate in
a wheelchair, with a laser rangefinder for safety has been developed and trialled with
able bodied participants (Ka et al., 2012), but not people with disabilities.
Outcome measurement and decision making tools
In order to ensure that the person using AT has a good functional outcome, there are
increasing numbers of evaluative tools. The use of the International Classification of
Functioning, Disability and Health [ICF] (World Health Organisation [WHO], 2001)
model is recommended (Steel & de Witte, 2011), in conjunction with effective
analysis (Schraner, de Jonge, Layton, Bringolf, & Molenda, 2008). The ICF is
internationally recognised as a good way of putting health and disability interventions
into a measurable context. Tools being developed include: the User Testing Toolset
(Woodcock, Fielden, & Bartlett, 2012); the Everyday Technology Use Questionnaire
(ETUQ) (Hllgren, Nygrd, & Kottorp, 2011); and, School-based Assessments for
Children (Watson & Smith, 2012). Modified psychometric testing (Warschausky et
al., 2012) is also a developing area.
Quality of life measures are important to researchers (Rigby et al., 2011), and are
shown to be valid. The WHO disability Assessment Schedule 2 (WHO-DAS-II) has
been recommended, and indeed improvements on the WHO-DAS II have been
shown for people who are given assistive devices (Raggi, Albanesi, Gatti, Andrich, &
Leonardi, 2010).
What is clear is that as technology is rapidly developing, the use of outcome
measurement needs a great deal of further thought and investigation.
Page 16 of 33
re
2. What are the trends
in the disability sector for emerging technologies
such as i-pad, i-pod, smart, and tablet devices, in particular for people
with ABI?
Applications Apps
There is limited evaluation of apps, but the promise of apps as memory devices,
cognitive, and instructional aids to assist with record keeping, and as communication
devices is rapidly developing (Sutton, 2012a, 2012b). As with other AT devices,
involving users, at all levels, to judge success is crucial (Steele & Woronoff, 2011).
Built in features in mobile phones such as cameras, microphone, accelerometer,
GPS receiver and touchscreens are useful and low cost supports for people with
sensory difficulties, people with mental health problems, epilepsy, diabetes and
communication issues. The potential for using apps for personal care, as a
controller of home and environmental controls as well as health monitoring is only
beginning to be realised. The literature in this space is nascent, especially when
considering that the Apple iPhone was released in 2007, the Samsung Galaxy
android system in 2010, and the Apple iPad in 2010. The majority of the information
and evaluation of apps for people with disabilities tend to be web-based lists (such
as www.janefarrell.com, or www.spectronicsinoz.com/article/iphoneipad-apps-foraac). Some have attempted to rate these (Alliano, Herriger, Koutsofas, & Barlotta,
2012), but it is clear that there is such an explosion of information it is difficult to
accurately assess and manage.
i-Pad and AAC

The price of many speech generating devices are a barrier to their purchase.
However, using a mainstream tablet device has been embraced due to mainstream
appearance, versatility and ease of supply (Slade, Massey-Westropp, & Stewert,
2012). The iPhone, iPod Touch and iPad, and their equivalent android technologies
are becoming widely used as therapy tools in Speech and Language therapy, in
particular due to their affordability, convenience and user friendliness (Fernandes,
2011).
Mobile devices and apps are replacing larger isolating Augmentative and Alternative
Communication devices, as they are readily available, inexpensive compared to AAC
devices and do not isolate the person (Atticks, 2012). However, the soft technology
enablers of speech pathologists, occupational therapists and day-to-day support are
still required (Shepherd, Campbell, Renzoni, & Sloan, 2009).
Recent developments stress the need for individual assessment to determine
specific communication needs. The devices and apps available may not always be
the best solution for people with complex communication needs, but show enormous
promise (Bradshaw, 2013).
Page 17 of 33
Mobile Phones
re
The potential of mobile phones is only just beginning to be realised. Barriers to the
adoption of cell phones with older adults have been highlighted, due to two main
reasons; one is the adoption of handset features (such as touchscreens) that are
unfamiliar. The second main reason identified is the confusing nature of the mobile
phone industry (Pedlow, Kasnitz, & Shuttleworth, 2010). This includes not only lack
of access and understanding of features, but also difficult to access and understand
menus and instructions of the telephone handsets themselves. For example, service
handbooks are provided only in electronic means through the phone.
Nguyen et al (2007) identified barriers to use of mobile phone technologies for
people with physical disabilities, including typing and control sites (Nguyen, Garrett,
Downing, Walker, & Hobbs, 2007). Whilst some of these points remain relevant,
there has been such a shift in mobile telephone technology, it is likely that the
barriers currently experienced are different to those identified in 2007, but this is not
presently published. Despite the usability of the current smart phone systems, for
people with more complex physical impairments, smart phone access remains an
area of great difficulty (Hreha & Snowdon, 2011).
When barriers are overcome however, there is the potential for smart phone
technology (via iOS or android) to provide support for participation and everyday
functioning. For instance, many new devices and systems incorporate virtual
sensors in conjunction with GPS systems can generate alerts when a user travels
out of range, or can measure potential falls (Doughty & Dunk, 2009). Calendar,
contacts lists and mail are now all included as standard on all smart phones.
3. What are the emerging technologies reported?

Table 2 provides a snapshot of promising technologies reported in the literature.
Technology Area
Access to and
control of
technology
Technologies reported
Eye gaze (continued advancements) (Ball et al., 2010; Biswas &
Langdon, 2011; Fager, Bardach, et al., 2012; Najafi et al., 2008)
Trackball EdgeWrite (Wobbrock & Myers, 2008)
Experimental intentional muscle contraction switch system (Felzer et
al., 2010)
EPOC neuroheadset (Lievesley et al., 2011)
Automatic speech recognition software (continued advancements)
(Young & Mihailidis, 2010)
Voice-activated joystick (for computing and powered
mobility)(Harada et al., 2008)
Microsoft Surface (Banes, 2009)
Data gloves (Tongrod et al., 2013)
Swype Input Method (for onscreen keyboard access) (Anson,
Brandon, et al., 2012)
Intelligent software (Horstmann Koester et al., 2007)
Page 18 of 33
reVoice-activation software (Fager, Beukelman, Fried-Oken, Jakobs,

& Baker, 2012; Judge et al., 2009)
Software/iDevice
Google Calendar (McDonald et al., 2011)
technology
iPad (for AAC, ECU control, and support with daily activities)
(Alvseike & Bronnick, 2012; Atticks, 2012; Bradshaw, 2013;
Rehabilitation Engineering Research Centre on Communication
Enhancement [AAC-RERC], 2011)
Apps (for AAC and support with daily activities) (Alliano et al., 2012;
Brainline, 2012; Doughty, 2011; Gosnell, 2011; Koehler, 2011)
Touch nTag (Konttila, Harjumaa, Muuraiskangas, Jokela, &
Isomursu, 2012)
EqTD: Equivalent Text Description (Anson, Smith, et al., 2012)
Video phone (Boman et al., 2012)
Microsoft Windows7 on-screen keyboard (Chung et al., 2012)
Advances of the Android operating system (i.e. more accessible and
capable of supporting AAC apps, etc.) (Higginbotham & Jacobs,
2011)
Mobility
Intelligent wheelchairs (Zeng et al., 2008)
Wheelchair anti-collision technology (Wang, Kontos, et al., 2011)
Hum-drive wheelchairs (Falk et al., 2012)
Single-switch navigation (Ka et al., 2012)
Wearable power-assist locomotor device (Tanabe et al., 2013)
Autonavigating powered wheelchair (Bresler, 2012)
LWDAC: Lightweight durable adjustable composite wheelchair
backrest
Support for
CareTV (van den Heuvel et al., 2012)
independent living
Activity monitoring systems (Price, 2007)
Service robots (Kent-Walsh & Binger, 2011)
Advanced integrated sensor networks (Bharucha et al., 2009)
Telecare monitoring systems (Cameron & Doughty, 2010; Doughty
& Dunk, 2009)
Electronic incontinence pad sensor (Fernandes et al., 2011)
Actigraph (Nijhof et al., 2012)
Table 2: Snapshot of assistive technologies
Page 19 of 33
re
4. Economic evaluation
According to Agree (Agree, 1999) the use of assistive technology differs significantly
from the provision of personal care. Specifically, she notes that the application and
use of assistive technologies does not demand ongoing involvement of other people
(be they carers or care providers), and therefore, increases the sense of
independence with which a disabled individual can meet their long-term care needs.
(p.427). It is clear that the use and application of such technologies will only become
most cost-effective if there is improved prescribing of equipment and services
(Dougherty, 2012); a point also noted by the Victorian Auditor General in their audit
of individualised funding for disability services (Victorian Auditor General's Office
[VAGO]. 2011).
In this report (2011), VAGOs recommendation 11 specifically notes that
individualised funding (and thus the provision of tailored assistive technology
solutions to people living with a disability) needs to be supported by through training
and guidance, staff consistency and fairness in assessing Individual Support
Package applications and allocating them and monitoring performance. The logic
here is that greater control is needed in assessing packages rather than control
regarding what each package should contain. Thus, by better matching individual
need to assistive technologies provided both allocative efficiency and maximum
flexibility in responding to the needs of people living with a disability are optimised.
Such an approach also helps to minimise (or potentially eliminate) waste while
ensuring that the response provided is not over-engineered as far as the risks to the
individual are involved (Doughty et al., 2012).
From a cost perspective, one study (Bamer et al., 2010) found that the cost of
assistive technologies represent only 3.3% of the annual cost of care in people living
with significantly disability (i.e. high assistive-technology needs). Dougherty (2012)
concludes that while set up costs of assistive technologies may be high initially due
to the cost associated with the acquisition of the assistive technologies, a longer
term return is obtained due to fewer hours of support being required. Furthermore, in
the case of people with poorer or unstable health conditions, Dougherty also
concludes that savings can also obtained by the person living with a disability
requiring less inpatient care as the technologies applied assist in keeping people
healthy and in their own homes. Hoenig et al (2003) share this view; with their
findings demonstrating that technological assistance might substitute for at least
some personal assistance in coping with disability.(p.335).
Specifically, people living with a disability who do not use assistive technologies
report about four more hours of help per week compared with those who do use
similar technologies. Furthermore, they note that their findings are consistent with
accepted and current models of the disablement process given that contextual
factors such as assistive technology actually modify the process and thus lessen the
impact and the cost of disability.
Page 20 of 33
By way of an estimatereof economic gains achieved through the use of assistive

technologies, it is fair to conclude that there is a relative paucity of cost-related
studies that are applicable in the current study. That said the studies that are
available generally examine costs associated with maintaining independence and
leading a fulfilling life in aged care settings (Al-Oraibi, Fordham, & Lambert, 2012)
research into the quantifiable gains in respect to health costs, it appears that the
number of negative events (i.e. falls) is significantly reduced and the cost of care
halved post incident when assistive technologies are employed.
Gains are not just possible in respect to fewer hours of support being required, as
the Rehabilitation Engineering Research Centre on Communication Enhancement
[RERCCE] (2011) have also identified that newer forms of assistive technology (i.e.
smart phones, tablets, etc.) facilitate communication and social connection, both
meaningful and appropriate outcomes for people living with a disability. As per
VAGOs conclusions (VAGO, 2011), RERCCE also recognise the challenges
associated with different forms of assessment being undertaken with this
potentially resulting in poor person-technology matches and/or over-engineered
solutions being implemented. Given these factors, along with the pace of change
inherent in such technologies, it is not surprising that RERCCE concluded that poorly
designed and implemented systems could undermine third party insurers/funding
(i.e. such as that from TAC).
In respect to electronic assistive technologies specifically, the literature is emergent
rather than fully developed; meaning that little by way of longitudinal or adequatelycontrolled studies into the impact and cost of electronic assistive technologies exist.
Fager et al (2012), for example, conclude that while access to electronic assistive
technologies for people with severe physical disabilities is improving, most
approaches that aim to create a systemic approach to their provision and use (i.e. to
enhance uptake and use) do not meaningfully interface with the development of such
technologies. This outcome, they suggest, represents a mismatch between actual
use and the development cycles of such technologies. Furthermore, a mismatch can
also be present when considering the impact of technology redundancy.
Redundancy from an assistive technology perspective most commonly means that
the technology in question has been superseded or abandoned (Rehabilitation
Engineering Research Centre on Communication Enhancement [AAC-RERC],
2011). When redundancy occurs, be that thorough the abandonment of a specific
technology or the rapid replacement of existing technology, the literature suggests
that funders should limit the range of options (rather than technologies) available
while also actively managing the consumable aspects of such technologies (i.e.
Internet access) (Andrich & Caracciolo, 2007; Rehabilitation Engineering Research
Centre on Communication Enhancement [AAC-RERC], 2011)
The issue of on-going cost (i.e. the consumable aspects of electronic assistive
technology use) is also of concern to funders and potential users, especially given
Page 21 of 33
re
the potential cost to funders
and/or users should users download large amounts of
data. While this is an issue locally given the relatively higher cost of Internet access
in Australia, this is not a phenomenon that is experienced internationally though;
where, for example in the U.S.A. cost of Internet access was only an issue in 5% of a
sample of 80 people living with ABI (Vaccaro, Hart, Whyte, & Buchhofer, 2007).
Regardless, many emerging electronic assistive technologies require cabled and/or
wireless Internet access in order to function as designed and required (e.g. using
mapping applications on smart phones or tablets). Without equal access to such
assistive technologies as well as to the Internet, people living with disabilities are
potentially not maximising their civic, social and recreational participation (Bryen,
Heake, Semenuk, & Segal, 2010; Vaccaro et al., 2007). Positive relationships have
been detected between internet use and well-being for people with physical
disabilities (Cheatham, 2012).
The notion of exclusion in respect to Internet access is receiving increasing attention,
especially as it applies to at-risk or vulnerable communities (Blank, 2008). People in
certain groups such as people living with a disability, the aging, and people from
low economic status backgrounds are often excluded from using assistive and
mainstream electronic technologies, either by technical or economic issues, or by
the ability to learn how best to use the assistive technology (Baker & Moon, 2008;
Vaccaro et al., 2007). People without Internet access have fewer opportunities and
enjoy poorer social inclusion compared to those who can readily and easily access
the Internet (Seale, 2011). Not surprisingly therefore, people living with ABI are
often excluded from using the Internet, even when they do have access (Vaccaro et
al., 2007).
Overall, it appears that a clear need exists for both cost and usage-related research
remains; particularly research that is longitudinal and outcome rather than processfocused. This is particularly important as the literature suggests that it is possible to
examine the relationship among cost, functioning and outcomes in respect to the
prescribing and use of assistive technologies by examining the cost associated with
not doing anything namely, the opportunity cost of not providing assistive
technology to people living with a disability (Schraner et al., 2008).
Page 22 of 33
re
Conclusions and implications

The area of assistive technology is rapidly developing. This leads to exciting
developments for people with disabilities in terms of accessing mainstream
environments, enabling participation, potential reduction in attendant care and
promotion of choice in self-care, productivity and leisure activities. However, this is a
rapidly developing field with iPhone in existence since 2007, and iPad and android
phones since 2010. The literature that has been developed tends to be opinion,
development or idea, rather than rigorous evidence. There is little published
literature on physical infrastructure of new devices, cloud technologies and their
capabilities, security and safety.
1. Cost effectiveness of personal care technologies:
a. The most convincing, highest level evidence on reduction in personal
care hours is around cost effectiveness of AT such as environmental
control for people with physical impairments without associated
cognitive impairments. Environmental Control Units are technologies
that have existed for some years, and are generally well established.
What is emerging though is the potential role of new and emerging
technologies to take over from specialist ECU devices. Although many
emerging iOS and android based phone and tablet systems have ECU
potential, the physical and human interface access has yet to be
determined.
b. Further research is indicated with (a) larger studies for the before
mentioned group (b) studies on cost effectiveness, using appropriate
methodologies for people with increasing levels of cognitive
impairment.
2. Barriers to AT use
a. There are many barriers to AT use, both person based, services based
and institution or service provider based.
b. One of the barriers to emerging (iOS, PC and Android programs and
apps) is lack of internet access. It has been stated that people who do
not have internet access are disadvantaged, particularly when this is
required to access programs and applications. Furthermore, many
programs and applications are only available by media such as iTunes,
which require credit cards to activate. People with disabilities,
alongside those who cannot physically access the internet are
excluded from participation in mainstream society.
i. The increasing use of the internet in order to access common
services (i.e. service system websites, school and learning
information etc.) creates a potential barrier for people with
disabilities if they are excluded from this. This concept should
be explored further.
Page 23 of 33
re are physical and/or cognitive barriers to service, the use of

c. When there
providers of support (i.e. multidisciplinary assessment and intervention
as well as personal supports) becomes essential. However, the best
mechanisms to achieve this are not clear from the literature.
Additionally, the workforce may not be familiar with the fast pace of the
emerging technologies.
i. Outcome measurement of the effectiveness of different types of
supports should be investigated. These outcome
measurements need to be creatively developed to be robust, but
accommodating of new technologies as they arise.
ii. Mechanisms to improve capacity of the workforce around
technology should be considered.
iii. Further research on the cost effectiveness, number and type of
teaching and training and the combination of these is an urgent
topic for further research.
iv. Assessment and prescription information should be clear and
directed, including supports and time estimated to learn and
become competent in the device for the end user.
3. Access to technologies: Access to technologies remains one of the greatest
barriers to using both every day and specialised technologies. People who
have more complex impairments or combinations of impairments have greater
difficulties with their access. Research tends to be reporting development or
providing opinion, or based on single case studies. This can be enhanced in
a number of ways.
a. Building capacity in the health care workforce as to the range and
breadth of access to input is essential
b. Evaluation of access, as well as goal directed interventions should be
provided and reported on where possible.
c. Given small numbers of people and their supports, multicentre
research and reporting is recommended.
d. Cost effectiveness and longitudinal studies, even on a single case
basis should be supported.
e. Long term support for individuals is required from professional
supports, even if to review mechanisms for accessing.
4. Memory supports: It appears that there is small but convincing evidence that
the use of electronic aide memoirs is generally preferable to paper based
systems. The automaticity of electronic devices whether a phone, watch,
Google calendar or others provide multiple inputs that aid memory of the
user. What is not clear is what the difference is between different supports.
5. iOS and Android technologies and AAC: The most convincing use of new
technologies replacing specialised technologies is in the field of AAC. There
remain several difficulties here. The specialised technologies work well for a
population who have been using them for a considerable period of time, and
Page 24 of 33
re
there is both maintenance
and people support (soft technologies). On the
other hand
a. Continued research into the use of AAC and emerging technologies,
and where the differentiation between specialised and other
technologies is most useful.
b. This is one area where controlled trials may be of some use. Given
small numbers this would need to be a multicentre research project.
Longitudinal studies, those which study quality of life and personal
preferences are priorities.
c. Development of workforce capacity is important at both the support
level as well as professional.
6. Smart phone technologies: Smart phone technologies have great potential,
but access to them remains difficult. Additionally, the pace of smart phone
technologies are so rapidly developing, that it is difficult to keep up with the
pace of development.
a. Policy, advocacy and advice regarding accessibility of mainstream
smartphone technology at a policy and company level should be
considered.
b. Accessibility of information for people with print, audio, cognitive and
physical difficulties should be mandatory at point of sale.
c. Use of developing systems such as GPS etc. should continue to be
investigated.
d. Consider collaboration with manufacturers to help solve accessibility
difficulties and use, as well as to realise the potential of these systems.
7. Personal care and Independent living
a. The use of in home technologies, personal alarms in mobile phones,
independent and care TV options as aid memoirs show great potential.
b. Prospective research studies could be considered, which have specific
aims of quantifying the influence of successful provision and training for
people with disabilities to evaluate the effect on reduction of personal
care hours (or not) as well as health and quality of life related factors.
8. Economic evaluation
a. The literature around economic evaluation is emergent, rather than
developed. Economic evaluation has tended to be short term, and
further research is required in terms of longitudinal effects of assistive
technology use on cost effectiveness, and efficacy.
Page 25 of 33
re
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Accompanying documents to this report

This evidence reviewre

ISCRR Research Report# 0413-022-026-RR1

The Research Question(s)

Implications and Conclusions

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

Models for provision of technology

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

Although the researchrequestions were developed through negotiation at the

ISCRR Research Report# 0413-022-026-RR1

Aids and equipment

Table 1: Search Terms

ISCRR Research Report# 0413-022-026-RR1

re PsychINFO (69 articles), Science Direct (91 articles), Sage

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

re developing; for example, the use of iCloud for storage of

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

re people with ABI, have shown that reminder prompts and

Access to and control technologies

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

Chung, 2012) are all re

ISCRR Research Report# 0413-022-026-RR1

i-Pad and AAC

ISCRR Research Report# 0413-022-026-RR1

3. What are the emerging technologies reported?

ISCRR Research Report# 0413-022-026-RR1

reVoice-activation software (Fager, Beukelman, Fried-Oken, Jakobs,

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

By way of an estimatereof economic gains achieved through the use of assistive

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

Conclusions and implications

ISCRR Research Report# 0413-022-026-RR1

re are physical and/or cognitive barriers to service, the use of

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

re Effects of Internet use on well-being among adults with

ISCRR Research Report# 0413-022-026-RR1

re Hotz, F., Wan, E., & Chau, T. (2012). Evaluation of an

ISCRR Research Report# 0413-022-026-RR1

re Journal of Assistive Technologies, 4(2), 15-25. doi:

ISCRR Research Report# 0413-022-026-RR1

ISCRR Research Report# 0413-022-026-RR1

re Gatti, V., Andrich, R., & Leonardi, M. (2010). Detecting

ISCRR Research Report# 0413-022-026-RR1

re Disability and Rehabilitation: Assistive Technology, 8(1),

ISCRR Research Report# 0413-022-026-RR1

re S., & Bartlett, R. (2012). The user testing toolset: a decision

ISCRR Research Report# 0413-022-026-RR1

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